One of the most common reasons people require medical care is their medical care.
This is a distinctly modern problem. In times past, doctors treated disease. Patients saw their doctor when they were sick. They had a problem; doctors offered help.
The doctor of today often improves health by removing healthcare. Itâ€™s one of my favorite tricksâ€”stopping nonsense.
Excess healthcare happens for many reasons. Three big ones are the conflating of risk factors with disease, overdiagnosis and the one-disease-one-treatment mindset.
A high cholesterol level is not a disease but it is treated with a pill. When women acquire the diagnosis of ductal carcinoma in-situ (DCIS), you can bet they, too, accept treatment. Worse, medical education, guidelines, and electronic health records conspire to favor the view of patients not as people but as lists of diseases. Indeed, the problem list is a big problem.
One way excess healthcare manifests itself is polypharmacy–too many pills. I chose to write about this topic in my last column over at theheart.org | Medscape Cardiology. Itâ€™s relevant for cardiologists because we prescribe lots of medications.
In fact, itâ€™s almost a mandate for us to prescribe at least four medications for patients with established heart disease. I call these the big-fourâ€”aspirin, statins, beta-blockers and ACE-inhibitors. They are the untouchables. The big-four drugs are mandated because they are â€œevidence-based.â€ Clinical trials “proved” their worth.
Ahâ€¦but if we slow down a bit and actually look at this evidence, we find reasons to doubt our certainty.
One obvious dilemma: once patients are prescribed these drugs, they stay on them indefinitely. Then, as people with heart disease age, and gather other diseases, they are put on more pills. In the one-disease-one-treatment framework, medication lists grow and grow.
A recent review paper in the influential Journal of the American College of Cardiology addressed the issue of long-term use of cardiac drugs.
The authors of this paper highlighted four gaps in the â€œevidence” base underlying long-term use of these drugs. I hadnâ€™t thought much about these obvious issues.
Disconnect between short-term studies and long-term use: Clinical trials that showed benefit of the big four heart drugs were carried on for short time periods, ranging from 1 to 4 years. Many patients take these drugs far longer than that. Does the short-term benefit carry on for years and decades? Maybe it does, maybe not.
Risk is not constant. In the post-heart-attack trials, most patients were enrolled right after the injury. Thatâ€™s a time when risk of death is high, and so medicines stand to benefit. After the heart heals, the risk of death decreases. Do drugs started during the high-risk phase of a disease confer the same benefit years later when the risk is lower?
What was may not be what is: Most of the clinical trials of the big-four drugs were done in a different era. The median publication date for the 82 beta-blocker trials: 1982. That was a time when heart attacks went on uninterrupted, as we did not have clot-dissolving drugs or acute angioplasty and stents. Most heart attacks now are aborted and injury lessened. Do drugs that act mostly to relieve strain on the heart confer the same benefit in an era when most heart attacks cause much less strain or injury?
Can findings of clinical trials be applied to everyday patients? Older patients and those with multiple medical problems are under-represented in clinical studies. That makes it hard to generalize the findings to everyday real-world patients. This a key issue for today’s doctors because our population is aging and the benefit/risk ratio of cardiac drugs lessens in older, sicker patients. Elderly patients are more prone to adverse effects of drugs. Do the benefits of these drugs apply to patients not represented in clinical trials?
The reason I emphasize these gaps in knowledge is not to say cardiac drugs are no longer useful. My aim is two-fold. One is to slow down the epidemic of polypharmacy. I see patients nearly everyday who have been taking cardiac drugs for years and years. I hadnâ€™t really thought about the fact that the evidence for benefit was so outdated and short-term.
The more important point of this exercise is to emphasize the value of critical appraisal of our evidence, and hence our defaults. This doesn’t just affect cardiologists. It’s a matter for all doctors and patients.
In his famous “This is Water” speech to Kenyon College graduates, the late American writer David Foster Wallace made it clear that you see a lot when you choose to notice the obvious.
The title and link of my column: Polypharmacy: An Obvious Problem in Need of Attention
7 replies on “Do cardiologists prescribe too many drugs?”
Dr. John, another common-sensical plea to your colleagues. Yet I wonder if prescribers are as listening as carefully to your plea as patients like me are. Just last week, I asked the guest speaker (a pharmacist) at a public 7-week forum on heart health to comment on recent studies about statins and associated risk of diabetes in some patients. His response was telling. He called the studies “silly” (perhaps a new peer review assessment term?) and seemed personally offended that I would even dare ask a question about side effects in the first place. This was coming from a pharmacist, but when a cardiologist is our guest speaker two weeks from now, I’m pretty sure we’re not going to hear one word about polypharmacy or deprescription or what you’re writing about here and at theheart.org from him either.
Q: Do you sometimes feel like you’re a voice crying out in the wilderness, or do you sense a growing upward trend in cardiology to embrace – or even consider – these concepts? Whatever your answer, I’m very glad you continue to speak and write.
Thank you for doing what you do.
Speaking of benefit or harm in the long term, and of diabetes… :
I’m walking through the ESC congress earlier this month when a guy stops me, nearly grabbing my arm. “Are you Mandrola?” he asks. “Yes,” I answer tentatively. “I love your column. You have changed the way I see things; the way I treat AF.”
Where was the young man from? South Africa. I thought, wow, social media is incredible. It allows different views–the skeptical, the less sure, the curious–to be spread. Social media disrupts the vertical hierarchy of medicine. When I started my career, this conversation would not have been possible.
Another example: Look at the Sprint Trial conclusions-without-results announcement. The only place you could read any semblance of sense was on blogs.
My views on writing is that at this point in my career it is important for me to be on the right side of the street. It’s why I am on the Cardiology Council of the Lown Institute. RightCare needs a voice. There are plenty of doctors out there with moral distress about all that is wrong with healthcare. They need to know there are others who feel the same way.They need to know they have a tribe.
Jay Schloss likes to quote Margaret Meade in his talks: â€œNever doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.â€ I think this aligns well with my motivation.
Perhaps EP’s could benefit from this advice also.
Antiarrhythmic drugs are still prescribed all too freely to patients, without cautionary warnings and without routine follow up.
To some folks, like me, they have been triggers for very scary side effects.
I was prescribed flecainide PIP, which sent me by ambulance to the ER with wild atrial flutter.
Then propafenone, the second dose of which made me gain seven pounds over 2 days and sent me by ambulance to the ER with flash pulmonary edema, although none of my docs has admitted it might trigger heart failure in a very small percentage of patients. I found out ex post facto by my own research on the web. Of course I am not a doctor or medical researcher and of course cannot prove the cause/effect relationship, and the docs, seeing 20-30 patients per day, are too overwhelmed to devote much time or interest to really investigate my near-death experience. I am just an anecdote. A passing blip on the radar.
None of my docs ever mentioned a word about potential side effects of the antiarrhythmic drugs they offhandedly prescribed. And none has ever brought up the research findings that major weight loss has now been shown to reverse afib and might be something to try first before swallowing (potentially) poison pills
GREAT post John! I often wondered exactly what you write. Although data are lacking to answer the rhetorical questions you pose about whether the benefit is still the same today â€” I’d guess the answer to most of these questions is, “probably not …”. THANKS again for writing!
Enjoy your writings and views as a newly diagnosed AFib patient.
Forty + years ago my Mother had a new doctor who deprescribed several of the medicines she had been on. She felt better that she had for several years because a health provider “did the right thing.”
What always disturbs me is the lack of belief when I describe side effects that hit me. For example, diltiazem gives me brain fog, blurred vision and halos and subtle other things.
When I mention this effect, I get blank stares.
Combine diltiazem, simvistatin and Pradaxa together, and see what you get. Those drugs combined increase the serum plasma levels of the simvistatin and the Pradaxa dramatically.
I was lucky I didn’t bleed to death. Forunately a pharmacist and a googgle search on my part found the newly discovered witches brew that this was. By the time this was sorted out, I looked like I had been in brutal fistfights, and I bled profusely if something touched my skin. I’m lucky I didn’t suffer major retinal damage as well. I was close.
Modern polypharmacy at its best.